Friday, March 20, 2015

SGR repeal isn’t a “doc fix”; it’s about fixing Medicare for good of patients

Members of Congress and the news media have a bad habit of referring to efforts to stop Medicare from arbitrarily cutting payments to physicians for taking care of their patients as the “Doc Fix.”  Typical is this story from CNN—“Bipartisan Love: Boehner, Pelosi strike deal to kick doc fix”—that reported on the release yesterday of an agreement between the two leaders on a bill to repeal the Medicare SGR formula, which I also covered in my blog post yesterday.

Calling SGR repeal the “Doc Fix” creates the impression that it’s a self-serving bill to benefit an influential group at the expense of others.  (Think about how’d you react if you read that a bill was an “oil company fix” or "tobacco industry fix”—you’d suspect the rest of us were being taken for a ride, which would probably be true).

Saying it’s a “Doc fix” makes the issue unnecessarily polarizing, because it implies that if Congress votes for permanent SGR repeal, it’s putting doctors ahead of a more deserving  group, like kids covered under the Children’s Health Insurance Program, when both are about improving access for patients, old and young.  (SGR repeal has become linked to CHIP, because the House leadership agreement permanently repeals the SGR, while it reauthorizes CHIP for just two more years, when many Senate Democrats want at least four years for CHIP).

Let me give you two reasons why the House leadership’s SGR repeal bill, summarized here, really is about fixing Medicare to make it work better for patients, not about fixing things to provide some unfair benefit to doctors:

1. It will improve access for patients enrolled in Medicare.  If the scheduled 21% SGR cut were to go into effect on April 1 as scheduled, there is no doubt that many (most?) physicians could no longer afford to see Medicare patients;  patients would begin to lose their doctors and would have great trouble finding new ones, as is the case today for many Medicaid enrollees.  Even if Congress decided to temporarily override the cut by freezing current rates for several more months, as it has done so many times before, physicians wouldn’t know what to expect when the patch again expires; such instability is causing many physicians to reassess how many Medicare patients they can see.  Plus, even with the temporary SGR overrides, Medicare payments have not kept pace with inflation for at least 13 years now—which in itself has caused some physicians to reassess their participation in the program.  For example, I know of a highly respected internist in Montana, a long time reader of this blog, who made the painful decision a few years ago to discontinue seeing any Medicare patients, because Medicare payments hadn’t covered his costs for years.  As long as we have the SGR formula, patches or no patches, the more we will see good physicians join this good Montana doctor in discontinuing or limiting participation in Medicare.

2. It will create incentives for physicians to provide higher quality, cost-effective and accessible care to patients.  It’s this aspect of the House’s SGR bill that has gotten the least attention from the news media and members of Congress themselves, when it is what the bill is mostly about, creating a better physician payment system.  In fact, the part of the SGR bill that repeals the SGR formula, and replaces the 21% cut from it with small positive updates over the next five years, is only 5 pages out of a 158 page bill!  What’s in the other 153 pages?

- Payment incentives for physicians who are able to demonstrate that they have made changes in their practices to benefit patients, like becoming Patient-Centered Medical Homes, a model that has been shown to improve quality and patient satisfaction and lower costs.

- Payment incentives for physicians who achieve better clinical outcomes, for using health information technology effectively,  and for delivering care more effectively and efficiently without sacrificing quality.

- Harmonizing and prioritizing measures to reduce the burden of reporting on physicians (accomplished by consolidating three existing Medicare reporting programs, each with their own measures, deadlines, penalties and incentives, into a single new Merit-based Incentive Program).

- A new option for physicians to earn even higher Medicare payments for participating in Alternative Payment Models (APM), like Accountable Care Organizations and advanced PCMHs, and for the medical profession to propose new models.

- More dedicated federal funding to develop good measures of quality, patient satisfaction and cost.

- And a new, federally funded program to help smaller practices.

These and other reforms made by the bill are all about changing Medicare payment policies to support greater value—quality, effectiveness, efficiency—to patients, the Medicare program, and to taxpayers who pay for it, and to support physicians who are willing to do their part to help achieve greater value for their patients. So yeah, you could say that the fix is in, but the fix is to make Medicare a better program for the patients enrolled in it, by changing the way that doctors are paid, not a “doc fix” implying an unfair sweet deal for doctors.

Today’s question:  “Doc Fix” or fixing Medicare to make it better for patients, what do you think the bill really does?


Robert J. Sobel, M.D. said...

We discussed this last year, and maybe the year before, and ... It's too late. Supporting more measures on us and burdens is not going to help. Maybe that small practice fund could help a few of the lucky (I did not read this year's version, so maybe you can expand on how that will save us and sign me up).

Little practices can't do any of this. That means, if the big ones can, the economy of scale is lost in more bureaucracy.

Would I be home more if I were a Medical Home? I'd love to get paid for quality, but it is too overwhelmingly challenging to actually provide quality care. To also worry about how you are going to be measured by whatever imperfect science is now the the cookbook au courant, is the same travesty that MU has become.

We've reviewed this before and you have never addressed why it is still the only policy strategy available (that is homes and the quality initiatives). While everyone is sidetracked on fixing docs, we're drowning in tasks fighting Medicare (like the other insurers) for strips and medications and other new technologies whose prices sabotage any money left for our services.

Until we see the fallacy of more bureaucracies and go about starting the deconstruction, there is no way Medicare, even with its harmonized, single Merit score, will be hospitable to private practice. It has been lost under our watch these last few years.

We'd be better off with a fix that entangles the big players in this cost constraint package, not contrived incentives that force us to spend more time in documentation than talking to patients. None of this saves us from the third party hassles.

As I approach a full year on EHR and 4 years as opt-out Medicare (though I still fight for those patients who pay to see me, so I am well aware of how it works), I am amazed at how far things have strayed from what private practice meant during my father's 51 years at it (1961 to 2012). Yes, there was excess and a surge in specialization. There was also the successful development of a patient-physician relationship structure that has truly contributed to the longevity increases that we cannot afford to take for granted.

Good luck to those who will try to persevere within. I hope we can co-exist and help patients without getting entrapped in fights over who gets credit in the ACO trickle-down. The third-parties owe us more, but they appear to have lost their way. The dysregulation from Hatch-Waxman to Part D to Biosimilar to SGR has led to a strange public-private hybrid. It functions far below what could easily be designed anew if we recognized how to constrain the big players. That would allow patients and providers to evolve with the times, being ready to adapt to the new as it is introduced in a financially sound way. Then, clinical utilization of the old versus the new could evolve solely as clinical realities, not perverse price differentials, dictate.

ryanjo said...

I filled out 3 "preauth" forms today for patients' meds. You know the drill, review the chart, answer the nonsensical questions written by insurance geeks: ("Use this line to describe every formulary drug, when tried, how long, what adverse effects. Include all ICD codes and if not complete, this request will be rejected. If not received by yesterday, your patient's Rx may be delayed..."). All were rejected, because patient didn't try the formulary drugs for 3 months! So I eRx in the formulary option. Rejected again, and I am sternly warned that the formulary drug is contraindicated in patient of this age. Now this is a Medicare D formulary -- why would it contain a drug unsuitable for Medicare age patients? This kind of insurance thuggery should be punished by CMS, not enshrined in its bureaucracy.

This is what us lowly ACP members do every day. Sorry but ACP's Medical Home, gun registration initiative, and new payment model, etc, etc, don't mean much. Don't have the time. Got a stack of mandatory chart audits to review, from contractors Medicare pays to collect my scalp.

But thanks ACP for looking out for us.